Provider Demographics
NPI:1821479635
Name:MARCELLUS R. CEPHAS MD LLC
Entity Type:Organization
Organization Name:MARCELLUS R. CEPHAS MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCELLUS
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:CEPHAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-487-6302
Mailing Address - Street 1:1405 MADISON PARK DR
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5627
Mailing Address - Country:US
Mailing Address - Phone:410-487-6302
Mailing Address - Fax:301-891-2080
Practice Address - Street 1:1405 MADISON PARK DR
Practice Address - Street 2:SUITE 1B
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5627
Practice Address - Country:US
Practice Address - Phone:410-487-6302
Practice Address - Fax:301-891-2080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3762101YM0800X
MDD0059532103TP0016X
MDR193679103TP0016X
MD138141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG01202OtherP/10